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Are We Single Agents, Double Agents, or Free Agents?

Simone, Joseph V. MD

doi: 10.1097/01.COT.0000291847.72455.35
Simone's OncOpinion

Consider the following quote:

“Traditionally, physicians have acted as [single] agents advocating for the patient's best interests, conforming to familiar professional ethics and societal expectations. With commercial managed care's growth and emphasis on cost control, health plans began imposing restrictions on physician's autonomy. Physicians often found themselves playing the role of ‘double agents,’ with potentially conflicting responsibilities to patients and insurers. Now in the post-managed care era, physicians have responded to mounting financial pressures with a range and intensity of activities that evoke images of ‘free agents’ defending their own financial interests and challenge established professional norms.”

The quote is from an article, “Financial Pressures Spur Physician Entrepreneurism,” by Hoangmai H. Pham, et al, beginning on page 70 of the March/April 2004 issue of Health Affairs. The article is one of a pair by the authors that are introduced by an editorial prologue, “Challenges for Physician Practice.”

The trends described in these articles will be familiar to oncologists, including:

  • ▪ Declining reimbursement for traditional physician services that is often not remedied by increasing volume.
  • ▪ Declining physician autonomy.
  • ▪ The growth of physician investment in nontraditional income sources that provide more generous reimbursement.
  • ▪ The growth of single-specialty practices that have greater economic power.

The authors used cardiology and orthopedics information to illustrate these points. Physicians favored (a) increasing the volume of services over competing on efficiency or quality; (b) increasing prices for services, and (c) retreating from less lucrative services—e.g., declining to care for Medicaid or Medicare patients.

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More Worrisome Trend

I would add a more worrisome trend—making major medical decisions that appear to be primarily for economic gain.

An example of this slippery slope was reported on the front page of the New York Times (21 March 2004). It described increasingly heavy use at a time when major studies show that heart attacks are not prevented by aggressive interventions such as coronary angioplasty and the insertion of stents for partially occluded vessels.

An interventional cardiologist from the University of Texas Southwestern Medical Center at Dallas provides a quote from the trenches of daily practice: “If you're an invasive cardiologist and Joe Smith, the local internist, is sending you patients, and if you tell them that they don't need the procedure, pretty soon Joe Smith doesn't send patients anymore. Sometimes you can talk yourself into doing it even though in your heart of hearts you don't think its right.”

The same cardiologist explained the enthusiasm for the aggressive procedures thus: “I think it is ingrained in the American psyche that the worth of medical care is directly related to how aggressive it is. Americans want a full court press.”



Although that public attitude is common in my experience as well, taking medical action on that basis blames the patient and dodges personal and professional responsibility. If there were no economic incentive to do the invasive procedure, what would the cardiologist recommend and actually carry out?

But what struck me most profoundly were two words in the article by Pham: “free agents.” Has it come to this? Are the authors and many finger-pointing payers right? Have medical specialists, oncologists included, evolved from a philosophy of (a) the patient first; to (b) walking fine lines between the often contradictory needs and desires of patient and payer, professional ethics, and personal economics; and finally to (c) now behaving primarily as animals in an economic jungle seriously concerned only with numero uno?

It is impossible to deny that there are physicians who behave as if the patient serves principally as a source of revenue, whose practices are focused inordinately on the business of medicine. They are the “free agents” described in Pham's quote.

More specifically, one might call them “econo-docs,” those in whose practices economics usually comes first and the “doc” part comes last.

These trends have more to do with oncology than we would hope. I will discuss the implications for oncology in my next column.

© 2004 Lippincott Williams & Wilkins, Inc.
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